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©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
Rituximab or plasmapheresis for prevention of recurrent focal segmental glomerulosclerosis after kidney transplantation: A systematic review and meta-analysis
Boonphiphop Boonpheng, Panupong Hansrivijit, Charat Thongprayoon, Shennen A Mao, Pradeep K Vaitla, Tarun Bathini, Avishek Choudhury, Wisit Kaewput, Michael A Mao, Wisit Cheungpasitporn
Boonphiphop Boonpheng, Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States
Panupong Hansrivijit, Department of Internal Medicine, UPMC Pinnacle, Harrisburg, PA 17104, United States
Charat Thongprayoon, Department of Medicine, Mayo Clinic, Rochester, MN 55905, United States
Shennen A Mao, Division of Transplant Surgery, Mayo Clinic, Jacksonville, FL 32224, United States
Pradeep K Vaitla, Division of Nephrology, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS 39216, United States
Tarun Bathini, Department of Internal Medicine, University of Arizona, Tucson, AZ 85721, United States
Avishek Choudhury, School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ 07030, United States
Wisit Kaewput, Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand
Michael A Mao, Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL 32224, United States
Wisit Cheungpasitporn, Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, United States
Author contributions: Boonpheng B performed the conceptualization, data curation, formal analysis, investigation, methodology, software, validation, visualization, preparation of original draft, review and editing of manuscript; Hansrivijit P performed the conceptualization, data curation, investigation, visualization, review and editing of manuscript; Thongprayoon C performed the conceptualization, supervision, visualization, review and editing of manuscript; Mao SA supervision, visualization, review and editing of manuscript; Vaitla PK, Bathini T, Mao MA, and Choudhury A performed the project administration; Bathini T, Kaewput W, and Choudhury A performed the project resources; Vaitla PK, Bathini T, Mao MA, Choudhury A, and Kaewput W performed the project supervision, review and editing of manuscript; Mao MA performed the conceptualization; Cheungpasitporn W conceptualization, investigation, methodology, supervision, validation, visualization, review and editing of manuscript; all authors had access to the data, and played a role in writing the manuscript.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
http://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Wisit Cheungpasitporn, MD, FACP, FASN, FAST, Associate Professor, Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States. wcheungpasitporn@gmail.com
Received: January 30, 2021
Peer-review started: January 30, 2021
First decision: May 5, 2021
Revised: May 10, 2021
Accepted: June 16, 2021
Article in press: June 16, 2021
Published online: July 18, 2021
BACKGROUND
Focal segmental glomerulosclerosis (FSGS) is one of the most common glomerular diseases leading to renal failure. FSGS has a high risk of recurrence after kidney transplantation. Prevention of recurrent FSGS using rituximab and/or plasmapheresis has been evaluated in multiple small studies with conflicting results.
AIM
To assess the risk of recurrence of FSGS after transplantation using prophylactic rituximab with or without plasmapheresis, and plasmapheresis alone compared to the standard treatment group without preventive therapy.
METHODS
This meta-analysis and systematic review were performed by first conducting a literature search of the MEDLINE, EMBASE, and Cochrane databases, from inception through March 2021; search terms included ‘FSGS,’ ’steroid-resistant nephrotic syndrome’, ‘rituximab,’ and ‘plasmapheresis,’. We identified studies that assessed the risk of post-transplant FSGS after use of rituximab with or without plasmapheresis, or plasmapheresis alone. Inclusion criteria were: Original, published, randomized controlled trials or cohort studies (either prospective or retrospective), case–control, or cross-sectional studies; inclusion of odds ratio, relative risk, and standardized incidence ratio with 95% confidence intervals (CI), or sufficient raw data to calculate these ratios; and subjects without interventions (controls) being used as comparators in cohort and cross-sectional studies. Effect estimates from individual studies were extracted and combined using a random effects model.
RESULTS
Eleven studies, with a total of 399 kidney transplant recipients with FSGS, evaluated the use of rituximab with or without plasmapheresis; thirteen studies, with a total of 571 kidney transplant recipients with FSGS, evaluated plasmapheresis alone. Post-transplant FSGS recurred relatively early. There was no significant difference in recurrence between the group that received rituximab (with or without plasmapheresis) and the standard treatment group, with a pooled risk ratio of 0.82 (95%CI: 0.47-1.45, I2 = 65%). Similarly, plasmapheresis alone was not associated with any significant difference in FSGS recurrence when compared with no plasmapheresis; the pooled risk ratio was 0.85 (95%CI: 0.60-1.21, I2 = 23%). Subgroup analyses in the pediatric and adult groups did not yield a significant difference in recurrence risk. We also reviewed and analyzed post-transplant outcomes including timing of recurrence and graft survival.
CONCLUSION
Overall, the use of rituximab with or without plasmapheresis, or plasmapheresis alone, is not associated with a lower risk of FSGS recurrence after kidney transplantation. Future studies are required to assess the effectiveness of rituximab with or without plasmapheresis among specific patient subgroups with high-risk for FSGS recurrence.
Core Tip: Focal segmental glomerulosclerosis (FSGS) is associated with a high risk of recurrence after kidney transplantation. Plasmapheresis and/or rituximab has been used to prevent recurrence with conflicting results. This meta-analysis is among the first to report that the use of preemptive rituximab, either alone or in combination with plasmapheresis, or plasmapheresis alone, did not alter the recurrence risk of FSGS after kidney transplantation.
